public private partnership in health service delivery: experiences & lessons

Public Private Partnership in Health Service Delivery: Experiences & Lessons

A.Venkat RamanFaculty of Management Studies

University of Delhi

WHY PARTNER WITH THE PRIVATE SECTOR?

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Omnipresence of the Private Sector

93% of all hospitals64% of all beds80% doctors80% of OP and 57% of IP ….are in the Pvt. Sector• (World Bank 2001)

Estimated at Rs. 1,56,000 Cr. in 2012 +Rs. 39,000Cr.. for health insurance (NCMH 2005)

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Share of Pvt. Sector- Non- Hospitalized care (60th NSS-2004)

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Share of Pvt. Sector- Hospitalized care (60(60thth NSS-2004) NSS-2004)

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Share of Private Sector in Rural Areas (NCMH,2005)

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Relative expenditure in the private sector - in Rural Areas (NCMH,2005)

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Who Pays for the Services?Percentage of Private Expenditure

(NHA-2004-05)

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Implications

>80% of health expenditure is out-of-pocket. (NSS 2005; NHA,2004-05)

Debilitating Effects on the poor: Liquidation of assets,

indebtedness. 40% of hospitalized & 2% in the country every year end

up BPL (World Bank, 2001).

Compounded by poor regulation of private sector

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Private sector is needed because....

India needs an additional750,000 beds520,000 doctors overall investment of Rs 1,50,000Cr.

80% likely to come from the private sector (NMCH,2005)

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PPP MODELS & TYPES

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Not all interactions between the Government and Private sector are PPPs

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Financing vs Delivery:Public vs Private modes

(Bloom, 2001)

Public Provision Private Provision

Public Financing

Public Hospitals?????

VoucherContracting??????

Private Financing

User Fee Hospital Autonomy

????????

Private Hospitals??????

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Common PPP Models

Contracting (‘in’ and ‘out’)Joint VenturesBuild/ Rehabilitate, Operate, Transfer Health Financing (Vouchers, CBHI, Illness fund) Mobile Health UnitsFranchisingSocial MarketingTechnology demos (e.g. Telemedicine)Public-Private Mix

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Core Principles of Partnership

True partnerships entail◦Relative Equality between partners◦Mutual Commitment to Public Health

objectives◦Benefits for the Stakeholders◦Autonomy for each partner◦Shared decision-making and accountability◦Equitable Returns / Outcomes

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PPP Models in Practice:

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Uttaranchal Mobile Health and Research Clinic

Clinical & Radio diagnostics through health camps, lab tests

Free to all BPL cardholders.

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Mobile (Boat) Health Service in Sunderbans, WB

Diagnostics; Consultation- health clinics; Drugs; Health promotion

All services are free; All beneficiaries are assumed to be BPL

SMS Hospital Jaipur Rajasthan

Radiological (CT/MRI Scan) Diagnostics

Free for all BPL Patients; Subsidized rate for others

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Karuna Trust, Karnataka

Management of PHCs and sub-centers; 24-hrs clinical services

Free services- diagnosis, consultation, treatment and drugs.

Shamlaji Hospital, Sabarkantha, Gujarat

Management of a government built CHC; 24-hrs services

Except select surgeries all services are free for poor patients

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Arpana Swasthya Kendra, Delhi(CO)

Management of Maternity health center under RCH

Free Lab Tests, ANCs, select surgeries, community health services, sanitation, IEC

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Rajiv Gandhi Hospital, Raichur Karnataka

Super-specialty clinical and surgical services

40% beds are for BPL patients; Free OPD services to poor.

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Karnataka Integrated Tele-medicine & Tele-health, Chamrajnagar

Tele-diagnosis and consultation in cardiac care and specialist care

Free diagnosis, medicines and treatment for the BPL patients

Yeshasvini Health Insurance SchemeKarnataka

Hospitalization and care for more than 1600 surgeries

Only for the members of farmers’ co-operatives and their dependents

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Chiranjeevi Yojana, Gujarat

Institutional deliveries through private obstetricians and gynecologists

Scheme is primarily for women from poor families, with prior ANCs from a govt. hospital

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Voucher Scheme, Haridwar, Uttarakhand

ANC, PNC Institutional Deliveries

Primarily for BPL women

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OTHER MODELS IN OPERATION

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Arogyasri Scheme, Andhra Pradesh

Hospitalization & Surgical Procedures (more than 800 procedures)

Free Hospitalization/ Medicines/Follow-up

Franchising / Social Marketing

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EMRI/ HMRI Hyderabad/ Ahmedabad……..Call 108

Emergency, Accident/ Trauma servicesALS / BLS

Regional Diagnostic Centres- Hub/SpokeMedicityCo-location of Specialty servicesDistrict Hospital + Medical College (Hub)Franchised /Accredited Health UnitsRBF – Incentive Contracts

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EMERGING MODELS

Key Lessons & Challenges in PPP: Indian Experience

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Political and Administrative Commitment

Half hearted support for PPPTop officials are enthusiastic, but

success takes them away- leadership vacuum;

Lower level officials suspect PPP as ‘privatization’ or show disdain towards the private provider

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Institutional Capacity Need for technical / managerial skills for

designing, negotiating, implementing and monitoring PPP contracts

Develop institutional capacity at all levels, including oversight role.

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Policy and Institutional Framework

Lack of policy driven strategy towards PPP in health sector. Need for a PPP policy.

Lack of information on Private sector thus poor regulatory leverage.

No institutional structures to manage PPP contracts. Need for specialized PPP cell in Health Dept.

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Social Context of PPPAntipathy or suspicion towards the

private sector and govt’s failure to regulate -raise suspicion.

Unwillingness of ‘civil society’ organisations to explore PPP as an option.

‘Squeamishness’ about profit making in services meant for poor patients

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Diversity and Complexity of Private Sector

Private sector is diverse; Predominantly individuals (owner operated units) and from both recognized and unrecognized systems of medicine;

Diversity of tariffs, thus complicating information on cost vs tariff and tariff negotiations

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Process of Contracting : Partner selection

Primarily ‘input’ based contracting rather than outcome based.

(Only) competitively selected partners are less effective.

Priorities of : ◦Govt. Officials: Compulsion of L1 &

Completing procedural formalities. ◦Private Sector: Winning the bid by all means

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Risk

Financial risk to the private partner- Non-timely release of funds; Fear of enquiry.

Risk of unsuccessful/ failed contract leading to lack of services – patinets suffer, resources wasted.

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Enabling conditions for successSuccessful partnerships are contextual.

Enabling conditions include ◦ leadership from both partners; ◦prior consultation; ◦relational / trust based contracting; ◦pilot testing, ◦timely payment; ◦periodic review and amendments / revision of

contract; ◦specific performance indicators…..

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Key Constraints Payment delaysPersonality styles and trust level Local political interference / political flip-flapsNon-revision of contract clauses (Tariffs) Lack of capacity or willingness to supervise /

monitor / guide the projectPerceptual and attitudinal orientation to

private sectorLack of clarity of the objective of PPP

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Limitations in Contract Features

Defining and verifying beneficiaries (BPL patients)- especially high cost services

Defining Quality or Performance or Outcome indicators;

Supervision and Monitoring mechanism;Timely revisions / updating of contract;Ombudsman for dispute settlement;Clarity on user fee

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Summary

Public-private partnership (PPP) is not privatization

Government continues to play a key role

Requires high degree of institutional capacity

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In conclusion….Public Private Partnership

……does help benefiting the poor. …………one of the pragmatic options for

health service delivery, but not an alternative to public delivery or better governance.

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THANK YOU

Ref. Book:A.Venkat Raman & J.W.BjorkmanPublic Private Partnership in Health Care in

India: Lessons for Developing Countries. Routledge, London, 2009

http://south.du.ac.in/fms/idpad/idpad.html A.VENKAT RAMAN FMS-DU

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